24 May 2021 KENNETH SMITH · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 7 Failure to make an appropriate decision on the level of supervision View source Failure to account for sedative medication changes in falls risk assessment View source Failure to scale up care and prompt urgent review when problems arise View source Failure to determine whether falls should be recorded in the Accident Record View source Delay in seeking mental health practitioner advice for progressive agitation View source Failure to specify a date for future review View source Failure to trigger serious or untoward incident review following repeated falls View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
KENNETH SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to make an appropriate decision on the level of supervision
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to account for sedative medication changes in falls risk assessment
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to scale up care and prompt urgent review when problems arise
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to determine whether falls should be recorded in the Accident Record
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls , resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Delay in seeking mental health practitioner advice for progressive agitation
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to specify a date for future review
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review . It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger serious or untoward incident review following repeated falls
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report
4 May 2020 Barry Wayne Preston · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Placement without a clear understanding of the person's needs View source Failure to provide suitable ward placement due to capacity and flow constraints View source Failure to supervise eating when supervision is required View source Lack of interagency understanding of roles and responsibilities View source Failure of care coordinators to lead support and best-interests processes in acute settings View source Unclear responsibility for care decisions and placement suitability assessment View source Failure to ensure food is served at a safe temperature View source Poor-quality care documentation View source Lack of coordination and ownership of care in acute settings View source Failure to recognise lack of decision-making capacity View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Barry Wayne Preston · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Placement without a clear understanding of the person's needs
Wider context from the report “7. His placement at Laburnum Lodge was made without a clear understanding of his needs . He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suitable ward placement due to capacity and flow constraints
Wider context from the report “2. The inquest heard that he was kept on wards that were not suitable for him or his needs . The inquest was told that this was due to capacity and flow issues within the Royal Bolton Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise eating when supervision is required
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised , he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of interagency understanding of roles and responsibilities
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place. There was a lack of understanding between agencies of roles and responsibilities under the integrated care model .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of care coordinators to lead support and best-interests processes in acute settings
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place . There was a lack of understanding between agencies of roles and responsibilities under the integrated care model.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for care decisions and placement suitability assessment
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure food is served at a safe temperature
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn . The burn did not contribute to his death but did cause significant additional discomfort.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Poor-quality care documentation
Wider context from the report “1. The quality of the documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long term catheter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of coordination and ownership of care in acute settings
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care . It was unclear as to who was making decisions and assessing suitability of placement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise lack of decision-making capacity
Wider context from the report “5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care . Acquiescence by him was seen as him understanding and having capacity .
” Open source report
1 Mar 2017 Thomas Moore Unsworth · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Restricted driver visibility of pedestrians at the junction View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Thomas Moore Unsworth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Moore Unsworth, aged 80, was a pedestrian crossing Great Moor Street in Bolton when he was hit by a left-turning bus on 28 January 2016 and died from a head injury. Evidence at the inquest raised concerns that the junction layout, building line and street furniture limited drivers’ views of pedestrians and created blind spots.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Restricted driver visibility of pedestrians at the junction
Wider context from the report “1. During the Inquest evidence was heard that:-
The driver of the bus that came into collision with Mr Unsworth gave evidence that the nature of the junction into which she was turning together with the position into which pedestrians are guided to cross the road meant that her view of such pedestrians was limited and in certain situations there was a “blind spot” in which she was unable to see pedestrians at all . Police Officers likewise gave evidence that as vehicles were manoeuvring round this junction their driver's views of pedestrians were limited by the building line and then restricted by street furniture .
The area in question is presently under reconstruction giving an opportunity for these issues to be reviewed and addressed.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review collision CCTV, inquest witness statements and the junction through a multi-agency site visit.
Verbatim wording from the response “To consider and address your concerns, a meeting was convened on 24th March 2017 with relevant local authority officers and Greater Manchester Police Area Traffic Manager from the Serious Collision Investigation Unit, at which a review of the CCTV footage from the time of the collision was undertaken, all witness statements obtained for the purpose of the Inquest were considered and a site visit was undertaken.” Source location Response from Bolton Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reconstruction works cannot be extended to the crossing area because that area is outside the current site investigation scope.
Verbatim wording from the response “3. Vehicle Blind Spots and Re-construction works” Source location Response from Bolton Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relocating the pedestrian crossing would not improve visibility because the building line would continue to obstruct motorists’ line of sight.
Verbatim wording from the response “Consideration has been given as to whether any risks would be reduced by alterations or relocation of the pedestrian crossing. Following investigation, I can confirm that the position of the crossing in relation to the junction is determined by position of the stop line, which in turn is determined by the swept path of vehicles turning into the junction. The distance between the stop line and the crossing must be between 2.0 - 3.0m and in this case the crossing could be re-located by approximately 1.0m towards Bradshawgate. However, this would have no benefit in terms of visibility between motorists and pedestrians as the building line would still obstruct the line of sight.” Source location Response from Bolton Council
Open published response
11 Sep 2015 George James Ainsworth · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Insufficient pedestrian crossing time at the Deansgate and Knowsley Street junction View source Failure to restrict pedestrians to the pedestrian crossing where drivers have a restricted view View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
George James Ainsworth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George James Ainsworth died at Salford Royal Hospital after being struck by a bus in Bolton and suffering multiple injuries. Concerns related to the junction’s 90-degree bend, restricted bus-driver visibility, the absence of guard rails limiting pedestrians to the crossing, and potentially insufficient time for pedestrians to cross.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient pedestrian crossing time at the Deansgate and Knowsley Street junction
Wider context from the report “i. The junction of Deansgate into Knowsley Street is a 90 degree left hand bend with no restrictions on the vehicles entering the junction, other than the pedestrian crossing. Greater Manchester Police gave evidence that there is a “pinch point” when two large vehicles, such as buses, attempt to negotiate the bend at the same time resulting in one or the other having to give way. There was further evidence that the driver of a bus at the junction from Deansgate into Knowsley Street would have blind spots on the vehicle together with a limited pre-junction view around the bend due to the building line, which would affect the driver’s view of the road, particularly to the front nearside of the vehicle. The blind spots and limitations to the driver’s view of the road occur at a time when a driver is negotiating a narrow bend where there is a “pinch point” at the apex of the bend. Accordingly pedestrians who are free to cross the road outside the areas of the pedestrian crossing are at risk due to the driver’s restricted view.
The presence of guard rails, particularly along the stretch of pavement on the left hand side from Deansgate into Knowsley Street from where Mr Ainsworth crossed the road, with the exception of the area of the pedestrian crossing, would take account of the driver’s restricted view and would prevent pedestrians crossing the road outside the area of the pedestrian crossing, where a driver would have a restricted view.
ii. The time allowed for a pedestrian to cross the pedestrian crossing may not allow sufficient time for some pedestrians to cross the junction between Deansgate and Knowsley Street and an increase of the pedestrian crossing time would allow sufficient time for all pedestrians to cross the junction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict pedestrians to the pedestrian crossing where drivers have a restricted view
Wider context from the report “i. The junction of Deansgate into Knowsley Street is a 90 degree left hand bend with no restrictions on the vehicles entering the junction, other than the pedestrian crossing. Greater Manchester Police gave evidence that there is a “pinch point” when two large vehicles, such as buses, attempt to negotiate the bend at the same time resulting in one or the other having to give way. There was further evidence that the driver of a bus at the junction from Deansgate into Knowsley Street would have blind spots on the vehicle together with a limited pre-junction view around the bend due to the building line, which would affect the driver’s view of the road, particularly to the front nearside of the vehicle. The blind spots and limitations to the driver’s view of the road occur at a time when a driver is negotiating a narrow bend where there is a “pinch point” at the apex of the bend. Accordingly pedestrians who are free to cross the road outside the areas of the pedestrian crossing are at risk due to the driver’s restricted view .
The presence of guard rails, particularly along the stretch of pavement on the left hand side from Deansgate into Knowsley Street from where Mr Ainsworth crossed the road, with the exception of the area of the pedestrian crossing, would take account of the driver’s restricted view and would prevent pedestrians crossing the road outside the area of the pedestrian crossing, where a driver would have a restricted view .
ii. The time allowed for a pedestrian to cross the pedestrian crossing may not allow sufficient time for some pedestrians to cross the junction between Deansgate and Knowsley Street and an increase of the pedestrian crossing time would allow sufficient time for all pedestrians to cross the junction.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request Transport for Greater Manchester’s Traffic Control Unit to review the pedestrian crossing timings and assess extending the green-man phase.
Verbatim wording from the response “Whilst the Council hasn’t received any complaints directly regarding the length of the time allowed for pedestrians to cross the road, the submission from ████████Mat the inquest being the first, it will request Transport for Greater Manchester man Traffic Control Unit, which is responsible for the installation and operation of the signals, to review the timings and see if there is an opportunity to extend the ‘green man’ timings.” Source location George Ainsworth - Response from Bolton Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate the suitability of zig-zag markings at the pedestrian crossing approaches.
Verbatim wording from the response “iv. On 14th September 2015 a further site visit was made by Malcolm Fairhurst of Bolton Council and ████████ of Greater Manchester Police (See Appendix 1 for qualifications and experience) to look at possible improvements to the junction and crossing as a consequence of the Coroner’s request. Suggestions included the addition of zig-zag markings to increase the conspicuity of the crossing, the installation of a TRIXI mirror to help drivers with blind spot visibility and some method to reduce vehicle speeds around the bend.” Source location George Ainsworth - Response from Bolton Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Deansgate and Knowsley Street junction, including its geometry, pedestrian crossing arrangements, guard-rail provision and relevant safety evidence.
Verbatim wording from the response “i. The Council has reviewed the junction as requested. This has involved looking at the geometry of the junction; the road network; a site inspection with Greater Manchester Police and a review of the provision of pedestrian guard rail. The Council is also grateful to the Coroner for allowing copies of the CCTV footage of the incident from both the bus and the town centre CCTV system to be made available to them which has been useful in carrying out this review.” Source location George Ainsworth - Response from Bolton Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A blind-spot mirror is considered unsuitable because different vehicles have different blind-spot positions and no suitable location is available.
Verbatim wording from the response “TRIXI mirrors are used at traffic signal junctions with left turns so that drivers of large vehicles can check for cyclists travelling up the nearside of the vehicle on which is a blind spot for many such vehicles which can result in left turning vehicles colliding with cyclists who are travelling straight on.” Source location George Ainsworth - Response from Bolton Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transport for Greater Manchester’s Traffic Control Unit is responsible for signal installation and operation, including reviewing pedestrian crossing timings.
Verbatim wording from the response “Whilst the Council hasn’t received any complaints directly regarding the length of the time allowed for pedestrians to cross the road, the submission from ████████Mat the inquest being the first, it will request Transport for Greater Manchester man Traffic Control Unit, which is responsible for the installation and operation of the signals, to review the timings and see if there is an opportunity to extend the ‘green man’ timings.” Source location George Ainsworth - Response from Bolton Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pedestrian guardrails are not considered necessary because assessment under national guidance found they were unlikely to improve correct crossing use.
Verbatim wording from the response “However, it also states that for many years now there have been calls to review the use of PGR as it inconvenienced pedestrians, cluttered up streets and made an unattractive environment giving vehicles a sense of priority in town centres. In the worst cases PGR has caused more accidents than it has solved as pedestrians walk around it in the carriageway or jump over it in order to get to their destination in the most direct route. In general, it is recommended that the installation of new guardrailing should not be considered if alternative safety measures could be used.” Source location George Ainsworth - Response from Bolton Council
Open published response
20 Dec 2013 Keith Samuel Peters · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Failure to allocate assessments to officers with sufficient availability for completion within the required period View source Failure to prioritise assessments approaching or exceeding the twenty-eight-day completion period View source Lack of a system for referring overdue assessments for reallocation to another officer View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Keith Samuel Peters · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Keith Samuel Peters lived alone with Type II diabetes, chronic pancreatitis and alcohol dependence, and was admitted to hospital after his sister became concerned about his condition; he died on 12 September 2013. Concerns included delays and lack of prioritisation in assessing his social care needs, and the absence of a system to reallocate cases when an assessment could not be completed within the required period.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate assessments to officers with sufficient availability for completion within the required period
Wider context from the report “Brief circumstances of matters of concern
(1) Mr Peters’ case was allocated to a Community Assessment Officer who was on annual leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters’ assessment within the required period.
(2) During the periods when the Community Assessment Officer was available there is no evidence of Mr Peters’ case being prioritised, neither when the twenty eight day period allowed for the assessment to be completed was approaching expiry, nor when that period had expired.
(3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight days required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise assessments approaching or exceeding the twenty-eight-day completion period
Wider context from the report “Brief circumstances of matters of concern
(1) Mr Peters’ case was allocated to a Community Assessment Officer who was on annual leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters’ assessment within the required period.
(2) During the periods when the Community Assessment Officer was available there is no evidence of Mr Peters’ case being prioritised, neither when the twenty eight day period allowed for the assessment to be completed was approaching expiry, nor when that period had expired.
(3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight days required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bolton Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for referring overdue assessments for reallocation to another officer
Wider context from the report “Brief circumstances of matters of concern
(1) Mr Peters’ case was allocated to a Community Assessment Officer who was on annual leave at the time, and whose future leave commitments resulted in her having limited time to complete Mr Peters’ assessment within the required period.
(2) During the periods when the Community Assessment Officer was available there is no evidence of Mr Peters’ case being prioritised, neither when the twenty eight day period allowed for the assessment to be completed was approaching expiry, nor when that period had expired.
(3) The manager of the North STARS team gave evidence at the Inquest that there was no system in place for Officers to refer a case back to the Manager for re allocation to another Officer when it became clear that an assessment was not going to be completed within the twenty eight days required.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop electronic monitoring and trigger functions to alert staff and managers to assessment timescales requiring prioritisation or reallocation.
Verbatim wording from the response “The service will develop a monitoring and trigger function within the electronic system for staff and managers to be alerted to timescales for risk assessment prioritisation or reallocation as necessary.” Source location 2013-0378-Response-by-Bolton-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide six-weekly formal supervision and daily case discussions where required, supported by a systematic approach to reprioritisation or reallocation.
Verbatim wording from the response “Action
Staff to receive formal supervision on a 6 weekly basis and case discussions on a daily basis if required. The service does accept that a more systematic approach would be of benefit to managers and staff to enable reaching the 28 day period to enable reprioritisation/reallocation as necessary.” Source location 2013-0378-Response-by-Bolton-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate staff and manager responsibilities for alerting case managers when assessment timescales may not be met.
Verbatim wording from the response “Action
Staff to be reminded of personal responsibilities to alert their case manager to cases where timescales may not be met.” Source location 2013-0378-Response-by-Bolton-Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The case did not appear urgent, and the allocated worker should have had sufficient time to complete the assessment.
Verbatim wording from the response “Area of concern
Mr P’s case was allocated to Community Assessment 1 who was on leave at the time, and whose future leave resulted in having limited time to complete Mr P’s assessment within the required period.” Source location 2013-0378-Response-by-Bolton-Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Unavailable referral information did not identify risks requiring prioritisation, while daily welfare checks found no concerns or increasing risks.
Verbatim wording from the response “Service Response
The service considers that there was significant information that was not shared at the point of referral that could have highlighted risks to the case worker and manager to prioritise casework.” Source location 2013-0378-Response-by-Bolton-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations